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      The improved quality of postoperative analgesia after intrathecal morphine does not result in improved recovery and quality of life in the first 6 months after orthopedic surgery: a randomized controlled pilot study

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          In orthopedic surgery, it is well known that the use of intrathecal morphine (ITM) leads to an improved quality of postoperative analgesia. Little is known how this improved analgesia affects the long-term course after surgery.

          Study design

          A randomized, double-blind trial.


          Academic medical center.


          Forty-nine patients undergoing total hip or knee replacement surgery in spinal anesthesia.


          Patients were randomly assigned to receive either 0.1 mg (n=16) or 0.2 mg (n=16) morphine sulfate intrathecally or physiological saline (n=17) added to 3 mL 0.5% isobaric bupivacaine for spinal anesthesia. As a function of the quality of the short-term postoperative analgesia, the effect on recovery and quality of life was evaluated at various time points up to 26 weeks after surgery.


          In both ITM groups, the additionally required postoperative systemic morphine dose was significantly reduced compared with the placebo group ( P=0.004). One week after operation, patients with ITM reported significantly less pain at rest ( P=0.01) compared to the placebo group. At discharge, in comparison with the 0.1 mg ITM and placebo group, the 0.2 mg ITM group showed a higher degree of impairment regarding pain, stiffness, and physical function of the respective joint ( P=0.02). Over the further follow-up period of 6 months after surgery, recovery and the quality of life did not differ significantly between the three study groups ( P>0.2).


          Morphine (0.1 mg) as adjunct to 0.5% bupivacaine for spinal anesthesia is effective to produce a pronounced postoperative analgesia with a beneficial analgesic effect up to 1 week after surgery. With this study design, the different quality of postoperative analgesia had no effect on quality of life and recovery in patients over the 6-month follow-up period. In the medium term, ITM may induce hyperalgesic effects.

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          Most cited references 37

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          Opioid-induced hyperalgesia in humans: molecular mechanisms and clinical considerations.

          Opioid-induced hyperalgesia (OIH) is most broadly defined as a state of nociceptive sensitization caused by exposure to opioids. The state is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain may actually become more sensitive to certain painful stimuli. The type of pain experienced may or may not be different from the original underlying painful condition. Although the precise molecular mechanism is not yet understood, it is generally thought to result from neuroplastic changes in the peripheral and central nervous systems that lead to sensitization of pronociceptive pathways. OIH seems to be a distinct, definable, and characteristic phenomenon that may explain loss of opioid efficacy in some cases. Clinicians should suspect expression of OIH when opioid treatment effect seems to wane in the absence of disease progression, particularly if found in the context of unexplained pain reports or diffuse allodynia unassociated with the pain as previously observed. This review highlights the important mechanistic underpinnings and clinical ramifications of OIH and discusses future research directions and the latest clinical evidence for modulation of this potentially troublesome clinical phenomenon.
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            German translation and psychometric testing of the SF-36 Health Survey: preliminary results from the IQOLA Project. International Quality of Life Assessment.

             M Bullinger (1995)
            International translation and psychometric testing of generic health outcome measures is increasingly in demand. Following the methodology developed by the International Quality of Life Assessment group (IQOLA) we report the German work with the SF-36 Health Survey. The form was translated using a forward-backward method with accompanying translation quality ratings and pilot tested in terms of translation clarity and applicability. Psychometric evaluation included Thurstone's test of ordinality and equidistance of response choices in 48 subjects as well as testing of reliability, validity, responsiveness and discriminative power of the form in crossectional studies of two samples of healthy persons and longitudinal studies of two samples of pain patients totalling 940 respondents. Quality ratings of translations were favorable, suggesting a high quality of both forward and backward translations. In the pilot study, the form was well understood and easily administered, suggesting high clarity and applicability. Thurstone's test revealed ordinality (in over 90% of the cases) and rough equidistance of response choices also as compared to the American original. On item and scale level, missing data were low and descriptive statistics indicated acceptable distribution characteristics. In all samples studied, discriminative item validity was high (over 90% scaling successes) and Cronbach's alpha reliabilities were above the 0.70 criterion with exception of one scale. Furthermore convergent validity, responsiveness to treatment and discriminative power in distinguishing between healthy and ill respondents was present. The preliminary results suggest that the SF-36 Health Survey in its German form may be a valuable tool in epidemiological and clinical studies. However further work as concerns responsiveness and population based norms is necessary.
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              Clinical global impressions

               W Guy (1976)

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                09 May 2017
                : 10
                : 1059-1069
                [1 ]Department of Anesthesiology and Intensive Care Medicine, Pain Clinic, Hannover Medical School, Hannover
                [2 ]Department of Psychosomatic Medicine, AHG Psychosomatische Klinik Bad Pyrmont, Bad Pyrmont
                [3 ]Department of Anesthesiology and Operative Intensive Care Medicine, Franziskus Hospital, Bielefeld
                [4 ]Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, St. Josefs-Hospital Cloppenburg, Cloppenburg, Germany
                Author notes
                Correspondence: Nilufar Foadi, Department of Anesthesiology and Intensive Care Medicine, Pain Clinic, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany, Tel +49 511 532 2489, Fax +49 511 532 3642, Email foadi.nilufar@ 123456mh-hannover.de

                These authors contributed equally to this work

                © 2017 Foadi et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research


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